A Qualitative Analysis of the Fertility Experience and Gender Identity in Young Women Following Hysterectomy for Benign Disease

Hysterectomy may impact young women’s perceptions of their gender identity and fertility status, with implications for qual- ity of life. However, research into this important area is limited, particularly among women with benign disease. To investigate gender identity and fertility in this population, semi-structured interviews were conducted with 18 women who underwent hysterectomy for benign disease at age 39 or younger. Women were asked to describe their experience of hysterectomy and how it affected their perceptions of their gender identity, fertility status and overall quality of life. Thematic analysis was used to analyse and code responses. Three themes were identified; Implications of Infertility, I am a Woman and Womanhood Compromised. Within these themes, 3 sub-themes were identified. Implications of Infertility comprised three sub-themes describing women’s varied relationships with their post-hysterectomy infertility: Plans Fulfilled, Acceptable Compromise and Persistent Grief. A novel finding was that women engaged in a “trade-off”, whereby relief of gynaecological symptoms outweighed their desire for a child/further child/ren. The study also found that women with an extensive history of infertility may have more trouble adjusting to the outcomes of their hysterectomy than women who were satisfied with their fertility history. Counselling around identity and how this can be influenced by fertility status may be needed. Further research into the psychological processes involved in the “trade-off” is also needed.

Gender identity · Hysterectomy · Infertility · Pre-menopause · Quality of life · Women’s health · Gynaecological surgery Hysterectomy refers to the surgical removal of the uterus and is a major gynaecological surgery world- wide (Hammer et al., 2015). Hysterectomy may be considered for numerous reasons including benign gynaecological conditions, particularly when more conservative treatments have been ineffective or have bothersome side effects (Laughlin-Tommaso et al., 2020). For chronic conditions such as endometriosis, adenomyosis and fibroids, hysterectomy may reduce physical symptoms such as heavy menstrual bleed- ing and pelvic pain (Laughlin-Tommaso et al., 2020). However, women may also experience psychological, social and emotional sequelae of this procedure (Bay - ram & Beji, 2010; Elson, 2002), with younger and/ or pre-menopausal women affected in ways that are unique to their life stage. This may include experienc - ing changes in gender identity (Elson, 2002 ; Elson, 2005; Cabness, 2010; Solbraekke & Bondevik, 2015) and conceptualisations of fertility, which in turn may impact their quality of life. Understanding the effect of hysterectomy on women’s quality of life is impor - tant, particularly as there is limited literature available to guide health professionals working in this field. Research in this area may also help women gain a bet- ter understanding of the broader risks and benefits of undergoing a hysterectomy. * Daisy Bottomley [email protected] 1 Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC 3010, Australia 2 The Royal Women’s Hospital, Flemington Road, Parkville, VIC 3010, Australia 3 Department of Obstetrics & Gynaecology, The University of Melbourne, Parkville, VIC 3010, Australia 278 Sex Roles (2023) 89:277–287 1 3 Gender Identity Following Hysterectomy Gender identity refers to a person’s perception of having a specific gender and often corresponds with a person’s sex at birth (Connell, 1995). Women’s gender identities include traits that have traditionally been considered feminine, such as passivity, emotionality and nurturance (Connell, 1995). Hysterectomy and its associated outcomes may alter a woman’s sense of femininity, and therefore her gender identity (Elson, 2005). Cessation of menstruation post-hys- terectomy may partially explain this identity adjustment. There is a strong association between menstruation and female gender identity with many women perceiving men - struation as connecting them to other women and as being a process that reinforces femininity (Elson, 2002). Fertil- ity loss in pre-menopausal women post-hysterectomy may also cause identity disruption. Some literature suggests that women’s reproductive capacity informs and shapes their gender identity (Alamin et al., 2020; Bell, 2019; Miles et al., 2009). Notably, there is variation in women’s expe- riences; some finding their sense of identity unchanged (Cabness, 2010) while others report an enhanced sense of self, likely associated with the significant reduction in gynaecological symptoms (Bell, 2019; Elson, 2002; Elson, 2005; Solbraekke & Bondevik, 2015). Fertility Following Hysterectomy Given the irreversible impact of hysterectomy on the abil- ity to carry a pregnancy, investigating how this is expe - rienced by women and what effect this may have on their quality of life beyond gender identity is important. Previ- ous research points to increased rates of worry, sadness, low self-esteem and relationship breakdown in women experiencing infertility following benign gynaecologi- cal disease (Culley et al., 2013). Similar outcomes may be expected in women following hysterectomy; however few studies have explored this issue (Bougie et al., 2020; Farquhar et al., 2006; Leppert et al., 2007). Leppert et al. (2007) investigated women (N = 1140) following hysterec- tomy for benign disease and found that 14% desired a child or more children. These women tended to be younger and were more likely to have higher levels of psychological distress at the time of and following hysterectomy. While this suggests a link between removal of reproductive abil- ity and decreased psychological wellbeing, the fertility

of the participants was not assessed, making it difficult to understand the impact of hysterectomy in the context of individual fertility history. Farquhar et al. (2006) described a relationship between hysterectomy and feelings of loss regarding fertility but did not assess women’s fertility backgrounds and how this may have affected their experience of grief post-hysterectomy. Nota- bly, both aforementioned studies included large numbers of women who were medically unable to bear children due to their older age at the time of their hysterectomy, hence infertility concerns may have been less significant than in a comparatively younger cohort. To date, only one study has investigated fertility and quality of life following hysterectomy in younger women. Bougie et al. (2020) studied the prevalence of post-hysterectomy regret in women (N  = 71) under 35 years who had undergone hysterectomy for benign conditions between 2008-2015. Participants completed a validated decision regret survey and health question- naire. Over 90% did not regret their decision and would elect to have the hysterectomy again, despite side-effects including permanent loss of fertility. However, 23.9% of women reported wishing to have another child fol- lowing hysterectomy. This research used a quantitative approach, and whilst post-hysterectomy outcomes were identified, respondents’ narratives were not explored in detail. Qualitative data has the potential to add a rich- ness to this understanding and tease out the nuances and complexities of this experience. For example, it is unclear why Bougie et al. (2020) found that the symptom relief experienced by young women following hysterec- tomy superseded the irreversible side-effect of fertility loss, particularly as previous studies have highlighted the negative impact of this loss (Farquhar et al., 2006; Leppert et al., 2007). The Current Study Further investigation is needed to understand how young women conceptualise their fertility following hysterec- tomy, including examining contextual information like previous childbearing and/or fertility difficulties, and age. This approach has the potential to provide information to medical professionals who are discussing the advantages and drawbacks of these procedures with their patients, and improve psychological services such as counselling, for young women. Consequently, this study aimed to investigate women aged 39 and under in terms of their perception of their gender identity and fertility following hysterectomy for benign disease, and how these perceptions may enhance or diminish their quality of life. It must be noted that this study was focused on the experiences of cis-gendered women. While the experiences of trans women undergoing hyster - ectomy as part gender affirming surgery are important and deserving of further scrutiny (Makhija & Mihalov, 2017), this is beyond the scope of this study. 279Sex Roles (2023) 89:277–287 1 3

This study used a qualitative approach to allow for a comprehensive and deep exploration and understanding of the experiences of young women post-hysterectomy. Within this framework, the research was underpinned by a phenomenological epistemology. This approach aimed to produce knowledge based on the subjective and unique experiences of the women participating in this research. It was interested in the women’s thoughts, feelings and reflections regarding their hysterectomy and was con- cerned with the quality and texture of these perceptions (Willig, 2013). The phenomenological standpoint does not necessarily try to uncover what is ‘real’ about the post- hysterectomy experience, but rather, is interested in the diversity and complexity of this experience for different women, accepting many possible interpretations of this experience. To achieve this, the women were interviewed using a semi-structured format; while the questions aimed to explore the quality of life areas of gender identity, fer - tility and body image, the design of the study allowed for the emergence of unanticipated themes that impact qual- ity of life. As such, the study has remained faithful to its phenomenological underpinnings; it displayed openness when speaking with the women and the researchers aimed to remain reflective and aware of any assumptions made when conducting the study (Sundler et al., 2019). Recruitment Ethics approval for the study was obtained from the Royal Women’s Hospital (RWH) Human Research Ethics Com- mittee (Project #20/27) on 11 November 2020. The current study was nested within a large-scale survey-based quanti- tative study at The Royal Women’s Hospital (RWH). That study (the parent study) is investigating the impact of age and parity on young women’s relief and regret following hysterectomy for benign disease. Some of the women who participated in the parent study also gave consent to be contacted for an interview in future. As such, the current study recruited participants from the parent study. Initially, 21 women aged 36 or under at the time of their hysterectomy were contacted by email regarding participa- tion. The researchers aimed to recruit the youngest possi- ble cohort (at the time of hysterectomy) as this population was of most interest to the researchers. From the initial group of 21 women, 13 expressed an interest in participat- ing in the study. Approximately 1-2 months after the initial inter - views, 10 more women (aged between 37-39 years at the time of their procedure) were contacted, to increase the sample size. Five provided consent, then were recruited (as above). In total, 18 women participated in the study. Participants and Procedure Participants were eligible to participate in the study if had undergone an elective, planned, hysterectomy for benign dis- ease. The participants also needed to have had the hysterec- tomy 6-11 years before the study, needed to be aged between 18- 39 years at the time of hysterectomy, and needed to have sufficient English literacy and communication skills to con- sent and participate in the study. As stated, data were collected via semi-structured inter - views. An interview schedule based on the empirical litera- ture and clinical experience was developed by the first and second author (GB and DB), with significant input from the senior author (LS), a clinical psychologist and women’s health expert, and associate investigators from the parent study, all gynaecologists. Interviews were conducted by DB and GB. Questions aimed at understanding the broad implications of hysterectomy on the women’s quality of life, and impacts on their fertility, gender identity, psychological wellbeing and sexuality. Data describing participant char - acteristics were accessed from the parent study. The inter - view data was transcribed verbatim by GB and DB, which involved listening and re-listening to the recorded interviews and documenting what was discussed, word for word. Researcher Positionality In terms of reflexivity, care was taken to recognise the researcher’s positions of privilege when interviewing the women, as highly educated, middle-class, cis-gendered white women. This relative position of power was dealt with in a sensitive manner, so as not to create feelings of intimidation or discomfort during the interviews. Further, the researchers took care to acknowledge their positions as outsiders to the experience of having a hysterectomy and aimed to approach the data with curiosity and interest, rather than imposing pre-conceived ideas around the procedure. Data Analysis NVivo (2020) software was used to store, organise and analyse the data. Thematic analysis was used, as outlined by Braun and Clarke (2006). Transcripts were read until familiarity was achieved. Codes were developed to con- dense the data and segment it systematically in preparation for analysis. Following this, codes were merged and rela- tionships between them were considered in the creation of themes. Emerging themes were then refined. Data was coded until saturation was reached; that is, until no new codes or 280 Sex Roles (2023) 89:277–287 1 3 themes emerged from the data set (Willig, 2013). Discus- sions about the codes and themes occurred throughout this process between DB, GB and LS. DB and GB each coded the data separately, and then reached a shared consensus on the codes and subsequent themes through discussion. Inter- rater reliability was tested using Cohen’s kappa. LS provided oversight and feedback regarding coding, emerging themes, and the refining of themes. Illustrative quotes were identi- fied and edited for clarity, and included in the results section to support the data. Data on participant characteristics were analysed using IBM-SPSS Statistics (Version 25).

Participant Characteristics Eighteen women participated in interviews, which ranged from 15-90 minutes in length ( Mean = 41 minutes). Mean age at the time of hysterectomy was 35-years-old and 44-years-old at interview. Most women were married and had had children prior to their hysterectomy. Endometriosis was the most common reason for the procedure. See Table 1 for detailed sample characteristics. Themes Analysis resulted in the emergence three themes and five subthemes. See Table  2 for a summary of themes and subthemes, frequencies, exemplary quotes and interrater reliability. Theme 1: Implications of Infertility This theme had three sub-themes and comprised women’s conceptualisations of infertility following hysterectomy and the impact on their quality of life. Plans Fulfilled Over half the women reported that their childbearing plans were fulfilled before their hysterectomy, and the infertility they experienced post-hysterectomy had little negative impact on their quality of life. In some cases, the hysterectomy resulted in a sense of relief as it provided long-lasting contraception, ultimately strengthening the quality of their intimate relationships. “I’d already had 4 kids…and I’d had my tubes tied, so I was more than happy to have the hysterec- tomy.” (P10) “Immense relief [following hysterectomy]… because I knew there was no way I was getting pregnant… you can continue on with life and not have that worry at all.” (P17) Some women did not have children at the time of hys - terectomy but reported that they never wanted nor intended to have them. These women experienced a sense that their plans were fulfilled and did not report that their quality of life was negatively affected by their infertility. Rather, this was a neutral or welcome side-effect. “I've never really cared about my fertility; I have never been interested in children. I've never wanted them… Table 1 Socio-Demographic and Clinical Characteristics of Partici- pants *Some women had more than 1 reason for undergoing hysterectomy **Some women had more than 1 mental health diagnosis at the time of hysterectomy. Of the women diagnosed with at least one mental health condition, 22% of the diagnoses were self-reported, and 33% and 44% were given by a general practitioner or mental health practi- tioner, respectively M(SD) Range Age at time of hysterectomy (years) 35 (3.4) 26-39 Age at time of interview (years) 44 (4.2) 36-51 Number of years since hysterectomy 9 (1.9) 6-11 N %

of performing hysterectomy Abdominal (includes laparoscopic) 14 78 Vaginal 4 22 Self-reported reasons for undergoing hysterectomy* Endometriosis 10 61 Heavy menstrual bleeding 8 39 Fibroids 4 22 Adenomyosis 3 17 Chronic pelvic pain 3 17 Prolapse 1 6 Adhesions 1 6 Polycystic ovaries 3 17 Relationship status at time of hysterectomy Married/Cohabitating 15 83 Unpartnered 3 17 Heterosexual Prefer not to answer 17 1 95 5 Had given birth to children prior to hysterectomy 15 83 Partner supportive of hysterectomy 14 78 Partner unsupportive of hysterectomy No partner at time of hysterectomy 1 3 5 17 Mental health diagnosis at time of hysterectomy** Depression 9 50 Anxiety 1 6 Post-traumatic stress disorder 2 11 Complex trauma 1 6 None 8 44 281Sex Roles (2023) 89:277–287 1 3 losing that was never really a factor in my decision and it's never impacted me since then.” (P09) “If you don’t want them [children] and you can’t have them you may as well get rid of the problem… it’s been a huge relief that I’ve never had to worry that I would become pregnant.” (P15) Acceptable Compromise A large proportion of the women, with varied fertility backgrounds, described experiencing fleeting grief associated with their post-hysterectomy infer- tility. However, these feelings were largely resolved by the time of interview. “Oh look, there are times where I wish there was another way to have gone through it all, but it is what it is, and I deal with it.” (P12) “After the recovery, I thought ‘Oh I want to be preg - nant again’… but then going through pain and nine months and then giving birth and looking after the baby, I'm not going to do that again.” (P07) In resolving this momentary grief, many considered their feelings from a pragmatic perspective. The difficulties they experienced prior to their hysterectomy (e.g., severe men- strual pain) seemed to outweigh the potential benefits of bearing children. As such, these women engaged in a ‘trade- off’; deciding that they could live with their infertility and the associated feelings of loss and grief as this came with the advantages associated with relief of their symptoms. “I think it was just knowing that I could no longer carry a child… I’m missing that bit… But then I’ll look at what I went through until I got to that point and I don’t know if I could have gone another 10 years living like that (in pain).” (P04) A subgroup of women with other medical con- ditions (e.g., cardiac disease) also engaged in this ‘trade-off’; however, their infertility was predomi- nantly related to these associated conditions rather than the hysterectomy. “I would have had more children before I decided to have a hysterectomy. The thing is I couldn't have any more children because I have a cardiac problem…it made my decision a lot easier.” (P06) Persistent Grief A minority of women expressed intense and persistent sense of grief tied to their loss of fertility. These women had complex medical histories that included a prior diagnosis of infertility. “I've wanted to be a mum since I was 4. I literally gave up career options that would affect my ability to parent. And so when it came to the point, where I was, like, ‘Oh, actually, you can't be a parent anyway’ that was a real kick in the head.” (P13) “Once the initial euphoria [from resolution of symptoms] had subsided, I really mourned, I really grieved it especially as my friends and my family began having children and continued having chil- dren, I felt really sad that I couldn't ever be in that position …I still feel grief about the fact that I only had one kid.” (P02) While the hysterectomy may have been the event directly causing the infertility, grief pre-dated the procedure and was the culmination of multiple, historical fertility diffi- culties. It is possible that the finality of the hysterectomy exacerbated this pre-existing and now persistent grief in this small subgroup of women. Table 2 Themes, Subthemes, Frequencies, Examples and Interrater Reliability Themes Sub-themes Counts/percentages Example Quote Cohen’s Kappa 1. Implications of infertility 1.1 Plans fulfilled 1.2 Accept- able com- promise 1.3 Persistent grief 10/18 (55.6%) 5/18 (27.8%) 3/18 (16.7%) “I'm quite content. I've got my son, I've got my daughter, very content” (P11) “Being upset and then just kind of going oh well, best thing I could do” (P08) “I don’t like the position that I’m in and I don’t like what my future looks like” (P13) .90 .95 .89 2. I am a woman 13/18 (72.2%) “It hasn’t changed my gender identity, I’m a woman, 100% through and through. Nothing like that is going to change the way I feel about being a female and just being me” (P14) .98 3. Womanhood compromised 5/18 (27.8%) “… perhaps I wasn’t as useful as a woman” (P02) .87 282 Sex Roles (2023) 89:277–287 1 3 Theme 2: I am a Woman The impact of the hysterectomy on participants’ gender identity was relatively benign. Most participants did not identify any specific changes in the way they conceptu - alised their gender identity and feelings of femininity. A sense of femininity in this cis-gendered cohort appeared to be well established prior to their hysterectomy. The women synthesised this femininity and their gender identity by drawing together their roles as mothers and wives, and through their employment. “I’m still that female role model for my kids, the female role model for students that I teach… just because I’ve had a hysterectomy, doesn’t mean that I am less, or that something is missing… my identity is about the impact that I have on the people around me and how I can improve the people around me, if I can help them.” (P16) The reported minimal impact of the hysterectomy on gender identity may have been due to the women’s percep- tion of the uterus as an internal organ, and therefore hid- den from view. As such, the hysterectomy did not remove a physically visible marker of traditional femininity, thus having a reduced impact on gender identity. “I'm quite happy with who I am and what I am. I think I would feel different if I had a mastectomy because then my boobs would be missing, that would make me feel less of a woman, whereas because it was internal, it didn’t particularly bother me.” (P03) “Because it [the uterus] is internal… if I had to have a mastectomy, that would be a lot more impactful than having a hysterectomy.” (P17) A small group of women commented that the hysterec- tomy contributed to increasing their feelings of feminin- ity and womanhood, mainly due to a decrease in negative symptoms and a resulting greater sense of freedom. For example, some women commented on their enhanced capacity to participate in leisure and work activities, as they were no longer concerned about excessive bleeding or pain. While this may have improved their quality of life, these opportunities may also foster an increased sense of gender identity, as they may feel more engaged with other women and able to behave in ways that reflect their desires as women. “It gave me confidence to feel like a woman without the stresses that come with being a woman… it took away any anxiety with the bleeding, what you can wear, what you can’t wear… the confidence to have sex… I felt very feminine afterwards.” (P10) “I feel a measure of freedom now more than I used to… because I don’t have to be distracted by worrying about the pain.” (P09) Theme 3: Womanhood Compromised For some women, the hysterectomy represented a partial loss of gender identity and resulted in diminished feelings of femininity. This sense of loss was tied to childbearing capacity (eg. loss of menstruation). “Knowing that I no longer had a part of me as a woman…it took me time to realize yeah, it is cool I don't have to bleed, but I've lost a part of me as a woman.” (P04) “[the hysterectomy] did make me want to just go, I’m [participant name], I'm not female. I don’t even have a womb. Because apparently some people say, ‘Oh, you can’t be female, unless you menstruate’.” (P08) Some women commented directly on their sense of iden- tity as a mother. While this was not the case for all women, including those with their desired number of children or dis- interested in becoming mothers, this was disproportionately felt by women who experienced feelings of loss and grief after their hysterectomy. “But maybe …less motherly, because you can't be a mother… because you're not normal.” (P13) I felt like [if] I wasn't going to be a mother again, per- haps I wasn't as useful as a woman.” (P02) Women conceptualised their failure as a mother as inter- twined with their failure as a woman, which ultimately, resulted in a diminished sense of self. In some cases, their perceived failure as both a mother and a woman resulted in negative self-perception, like poor body image. “I felt like a failure as a mother and as a woman because my body wasn't working. I couldn't deliver my own child myself and my body wasn't working properly then, it's still not working properly now. It's failing me, it's just not good enough, it's disgusting and useless.” (P01)

Hysterectomy for benign disease is a common treatment that may impact young, pre-menopausal women in ways that may be particularly challenging at their life stage. This study aimed to understand the sequelae of this surgery on qual- ity of life specifically regarding perceptions of fertility and 283Sex Roles (2023) 89:277–287 1 3 gender identity. The themes identified illustrated women’s varied relationships with their post-hysterectomy infertil- ity, depending on whether their childbearing plans had been fulfilled. Most participants had completed their families by having children or had never wanted children, thus were not adversely impacted by their infertility. Many women engaged in a “trade-off” whereby relief from gynaecologi- cal symptoms outweighed their desire for a child or further children. This is a novel finding and further research into the psychological processes involved in this appraisal is needed. Notably, this “trade-off” was not experienced by all women, with a small number of individuals with extensive histories of infertility continuing to experience grief post-hysterec- tomy. This suggests that a subgroup of women may have more trouble adjusting to the outcomes of their hysterectomy and require additional psychological support. Considering the post-hysterectomy infertility experiences of this cohort in the context of existing literature is chal- lenging, due to limited data. However, the strong sense felt by women of having achieved their reproductive intentions mirrors experiences reported by post-menopausal women (Dillaway, 2020; Ilankoon et al., 2020; Salis et al., 2018), including feeling that they have not only biologically, but also psychologically, surpassed their childbearing years (par- ticularly when paired with a sense of having completed their families) (Dillaway, 2020). While most ‘young’ women in this study were medically fertile at the time of their hyster - ectomy, they psychologically considered their childbearing years to be over as their familial plans were fulfilled. As such, they did not seem to attach significant emotional meaning to the loss of fertility; their hysterectomy simply being a process that led to improved quality of life. Some women coped with feelings of loss associated with their infertility by reflecting on the benefits of their symptom improvement. This concept builds on the “com- promise” suggested by Markovac et al. (2008), that some women resolve feelings of wanting another child by consid- ering their lack of pain. Bougie et al. (2020) also found that women did not regret their hysterectomy, despite relatively high numbers desiring a larger family. The reasons given as to why these women could resolve the feelings of loss asso- ciated with their hysterectomy involved factors including collaborative decision-making with medical professionals and possessing a high level of perceived autonomy when considering the procedure (Bougie et al., 2020). The current study suggests that it is the “trade-off” that women make following their procedure that influences the low level of hysterectomy regret found despite the desire for a child or further children. Unsurprisingly, this “trade-off” was not universal; a smaller number of women experienced persistent grief fol- lowing their hysterectomy that was directly tied to their infertility. This is broadly consistent with other research, which indicates that fertility loss after hysterectomy may be linked to increased psychological distress and regret for some women (Leppert et al., 2007 ; Farquhar et al., 2006). Beyond these studies, there has been little in the literature examining the complexity and mechanisms associated with women’s grief following hysterectomy. Women in the cur- rent study each felt their grief over an extended period of time, and this preceded their hysterectomy. It is possible that prior, ongoing difficulty with fertility (which may dis- proportionality impact women who undergo hysterectomy for benign conditions, such as endometriosis) (Culley et al., 2013), may play an important part in the onset of this psy - chological distress and subsequently, may worsen quality of life. These experiences of long-term grief are consistent with the infertility literature more broadly (Ferland & Caron, 2013; McBain & Reeves, 2019), including suggestions that women who remain involuntarily childless tend to experi- ence their grief indefinitely even if they eventually adjust to their circumstances (Ferland & Caron, 2013). Most women reported stable or enhanced gender identity post-hysterectomy, which is in line with previous literature in the cis-gendered population (Cabness, 2010; Elson, 2005; Solbraekke & Bondevik, 2015). However, the current study suggests a novel rationale for the stability of gender identity. Previously, it has been suggested that menstruation and the presence of the uterus are important factors in constructing women’s gender identities (Elson, 2002) and the removal of these processes/organs may lead to diminished feelings of femininity. Yet many women in the current study did not assign this meaning to their uterus or menstruation but commented that external physical markers like breasts were more important for maintaining their femininity. This find- ing is reflected in literature on women undergoing mastec- tomy; the removal of the breasts representing a potential challenge to femininity and decreased feelings of womanli- ness (Glassey et al., 2016). It is possible that the removal of visible indicators of femininity is more detrimental to women’s perceptions of gender identity than the removal of features hidden from personal and public view. The idea that external expressions of femininity are important in maintaining gender identity may also explain why after hysterectomy, some women in this study experi- enced identity enhancement due to an increased capacity to demonstrate their femininity (e.g., ability to wear tradition- ally feminine dresses). This is consistent with the findings of Solbraekke and Bondevik (2015) and as such, hyster - ectomy may augment and strengthen a woman’s sense of gender identity. Markovic et al. (2008) similarly suggested that some women could participate in more social and occu- pational activities post-hysterectomy, which increased their ability to embody their femininity in practice. The current 284 Sex Roles (2023) 89:277–287 1 3 study builds on this research and suggests that in the Austral- ian context, hysterectomy may reinforce identity stability or generate identity enhancement for some women. A small portion of participants linked their hysterectomy to a decreased sense of femininity, as their perception of themselves as mothers and women was challenged post- procedure. Notably, these participants had all experienced long-standing fertility difficulties. There is evidence that protracted infertility may not only disrupt, but also prevent the formation of gender identity in women, particularly as it pertains to femininity and womanliness (Alamin et al., 2020). The current study suggests that it is perhaps not the hysterectomy in isolation that causes gender identity disrup- tion, but rather, that the hysterectomy further diminishes a woman’s sense of gender identity which has already been impacted by infertility. Ultimately, the contrasting themes regarding gender identity support the overarching findings of Elson (2005), who acknowledged the variability in women’s relation- ships with their gender identity following hysterectomy. This study illustrates that women are diverse in their con- ceptualisations of femininity and womanhood and derive identity from different aspects of their lives. While some women tie their identity to their role as mothers (or lack thereof), others are perhaps moving towards more ‘mod- ern’ perceptions of what it may mean to be a woman. For example, some women linked their identity to how well they performed in their occupational role. As such, this study suggests that whether gender identify is enhanced, stable or diminished post-hysterectomy may depend upon a woman’s context and how she conceptualises her identity.

and Future Research Directions The cross-sectional study design was both a strength and a limitation. The study aimed to recruit women once a substantial period had elapsed after their hysterectomy, so that participants had had time to process, consider and contemplate the implications of the hysterectomy on their quality of life. These longer-term reflections on the hys- terectomy experience are lacking in the literature and have direct clinical utility for health professionals who may be able to communicate these longer-term experiences to women considering the procedure. However, as the aver - age time between interview and hysterectomy was 9 years, the absence of shorter intervals may have impacted the breadth of the post-hysterectomy experiences reported. Indeed, there is evidence suggesting that women’s quality of life differs depending on the length of time since recov - ery (for example, some women have a decreased quality of life immediately after hysterectomy which improves over time (Lee et al., 2009). It is unclear why this improvement occurs, and as the current study was not longitudinal, this trajectory could not be evaluated. However, further study of this would provide valuable information on the entirety of the post-hysterectomy experience. Another limitation of the study was that the participants were recruited from a specialist metropolitan women’s hospital (RWH). While the women would have received top-tier medical care, the study was conducted on a single site and therefore cannot be generalised to other groups of women. These include those that receive their hysterecto- mies in private hospitals or in regional centres, which may differ in terms of quality of care provided. Future studies might consider including women from a diverse range of private and public hospitals, to ensure that different care experiences prior, during and following hysterectomy are captured. Practice Implications The current study suggests that for most women who undergo hysterectomy, the procedure vastly improves qual- ity of life. However, there are some women who experience grief associated infertility and associated gender identity difficulties. It is therefore important for health care work - ers to gauge each individual woman’s fertility background prior to their hysterectomy. The findings from this study indicate that women with an extensive history of infertility may have more difficulty adjusting to the outcomes of their hysterectomy; thus adequate psychological supports should be available and accessible to these women. Counselling around identity and how this may be influenced by fertility status may also be required.

The current study sought to understand the post-hysterectomy experience of women younger than 39 at the time of surgery, specifically in relation to perceptions of fertility and gender identity. Findings from the study generally support previous literature, particularly as it pertains to improvement in qual- ity of life. However, there are novel findings from this study that require further research. The finding that women engage in a “trade-off” where desire for a child/further child/ren is outweighed by the relief associated with the elimination of gynaecological symptoms is worthy of exploration, particu- larly the psychological processes involved in this appraisal. The relationship between infertility and gender identity in this study, in the specific context of hysterectomy is also an area that could be re-visited in future research. The findings from the current study can be used to form part of a prelimi- nary evidence base around the post-hysterectomy experience and can inform health professionals working in this area. 285Sex Roles (2023) 89:277–287 1 3 Interview Schedule Hello This is calling/checking in about the study investigating quality of life after hysterectomy for benign disease. Thank you for agreeing to be interviewed for this study. Let me just remind you about the study. The aim of this project is to learn more about how hav - ing a hysterectomy for benign disease affects quality of life. Specifically, we are interested in learning about the impact of hysterectomy on female identity, body image, fertility, sexual functioning and sexuality and psychological func- tioning. The interview is going to be recorded and will be transcribed and then analysed. The recording will be stored in a secure location and destroyed after the completion of the study. If at any point you would like me to stop the interview or the recording, please let me know and I can do that. This interview can also be conducted across multiple sessions to break it up, if needed. If it appears that it may be appropriate to pause or stop the interview, I may suggest this. If there are any questions here that you do not want to answer, or you wish to have a break or stop, please just let me know and we can do that. If, after or during this interview, it seems that you might benefit from psychological support, we can discuss options for referral and/or debriefing. Do you have any questions before we continue? First, I am going to ask you a few background questions. These are not recorded. I will tell you when I am going to start the recording.

questions (for verification, not recorded) • When were you born? • When did you have your hysterectomy? (approximate month/year) I am now going to start recording Please confirm your consent to this audio-recorded interview 1. How did you come to have a hysterectomy? Prompt: What experiences led you to consider hav- ing a hysterectomy? Prompt: Do you recall what type of hysterectomy you had? (Were your ovaries or cervix removed as well?) Prompt: What symptoms were you experiencing prior to your hysterectomy? Prompt: How long were you having these symptoms prior to surgery? Prompt: How did your symptoms affect your day to day life (probe work, family, partner, friend domains) 2. What impact did the hysterectomy have on your symp- toms, if any? Prompt: can you describe the course of your recov- ery? Prompt: Did you notice that things improved quickly? Go up and down? Take a long time? In this research we are interested in understanding how your hysterectomy has changed your quality of life. By quality of life we mean the standard of health, comfort and happiness you experience. Quality of life can affect different areas, some of these being physical, psychological, social, family and environmental areas. With this in mind... 3. Can you tell me how the hysterectomy has affected your QoL, if at all? 4. How has your body changed physically, if at all, since undergoing the hysterectomy? 5. Have those changes impacted your body image? What I mean by body image is the way you think and feel about your body. Prompt: Have these thoughts or feelings impacted how you perceive your level of physical attractiveness? 6. How does your body image impact your life (QoL) more generally? One of the more specific interests we have in this research is understanding how a hysterectomy can impact a woman’s sense of identity. What I mean by identity is how you see yourself, what makes you, and characteristics that define you. Specifically, we’d like to know how you feel about your gender identity, that is, to what extent you feel like a woman, and your feel- ings of femininity. 7. Can you tell me how the hysterectomy has changed your gender identity, if at all? Prompt: can you give me a specific example of how the hysterectomy has made you feel this way? Prompt: what thoughts do you have when you feel this way? 8. How does your sense of gender identity impact your life (QoL) more generally? Prompt: Is your happiness or health impacted by your sense of gender identity? Now I’m going to ask you a few questions about your fertility. What I mean by fertility is your ability to have children. 9. Did your perceptions of your fertility influence your decision to have a hysterectomy? 10. How have you felt about your fertility since the hys- terectomy? 286 Sex Roles (2023) 89:277–287 1 3 Prompt: have you wanted the option to become preg- nant since the hysterectomy? 11. What influence do you think your age at the time of your hysterectomy had on your decision to have the surgery? Prompt: Do you think you were too young to make the decision to have a hysterectomy? Another focus of this research is understanding how, or if at all, having a hysterectomy affects a woman’s sexual functioning and sexuality. When I talk about sexual functioning and sexuality, I am talking about a range of things, such as your desire to have sex, your satisfaction with sex, and your feelings of intimacy with a partner. 12. Can you tell me a bit about what your sex life was like before your hysterectomy? 13. How has your sex life changed, if at all, since having the hysterectomy? Prompt: Can you say whether you think this was as a result of the hysterectomy? Prompt: Can you give me a specific example of how it has changed? 14. How has the way you think and feel about yourself as a sexual being changed, if at all, since having a hyster- ectomy? Prompt: How do these thoughts and feelings impact your sex life? 15. How has your sex life since your hysterectomy changed your quality of life, if at all? Prompt: How has it changed? Prompt: Has it changed over time? 16. How has having a hysterectomy affected the intimacy in your relationships, if at all? By intimacy I mean the feelings of emotional and physical closeness in your relationship. Prompt: Has it changed over time? Prompt: Has it been different with different partners? 17. How prepared and informed do you think you were about how having a hysterectomy would affect your sexuality and sexual functioning? 18. How has your overall mood changed, if at all, since having your hysterectomy? Prompt: what was your mood generally like prior to your hysterectomy Prompt: what has your mood been like generally since having your hysterectomy? Prompt: are there any other feelings (anxiety, stress) you feel since having your hysterectomy? 19. In retrospect, what do you think of your decision to have the hysterectomy? Prompt: Do you regret it? Do you feel relieved? Prompt: Would you do it again and why/why not? Prompt: What would you do differently? 20. Do you think, in retrospect, that you were adequately informed and your expectations were well managed about the outcome of the surgery prior to you having a hysterectomy? Prompt: Has that changed over time? Prompt: What was missing and what do you wish you knew now? Prompt: Importantly, would that change your deci- sion if you had known that now. 21. Are there any general comments you would like to make in relation to your hysterectomy? 22. Do you have any questions? Thank you for your time. End recording Authors’ Contributions DB, GB, LS and CR, contributed to the design of the research, DB and GB collected the data, LS, GB and DB ana- lysed the data, DB wrote the manuscript, and LS, GB, CR, UD, MH and CC reviewed the manuscript and provided feedback. DB imple- mented the feedback and prepared the manuscript for publication. Funding Open Access funding enabled and organized by CAUL and its Member Institutions. Data Availability The datasets generated during the current study are available from the corresponding author on reasonable request. Declarations Ethical Approval and Consent to Participate Ethics approval was received from the Royal Women’s Hospital Human Research Ethics Committee (Project #20/27) on 11 November 2020. Consent to partici- pate was obtained from all individual participants included in the study. Consent for Publication The participants provided consent for the research to be published. Conflict of Interests The authors have no conflicts of interest to de- clare. Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. 287Sex Roles (2023) 89:277–287 1 3

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